Publicity after publication of the Women's Health Initiative and the Million
Women Study has lead to women stopping hormone replacement therapy. They may
then be troubled with hot flushes and night sweats (vasomotor symptoms) or
pain during intercourse (dyspareunia) and are concerned about their risk of
osteoporosis. Alternative and complementary therapies are discussed.

There is little scientific evidence that complementary and alternative therapies
can help menopausal symptoms or provide the same benefits as conventional therapies.
Yet many women use them, believing them to be safer and “more natural”.
In the UK more than one in ten adults visit a therapist each year [Thomas et
al 2001]. The choice of treatments is confusing and, unlike conventional medicines,
not much is known about their active ingredients, safety or side effects or
how they may interact with other therapies. They can interfere with warfarin,
antidepressants and anti-epilpetics with potentially fatal consequences. Some
herbal preparations may contain estrogenic compounds and this is concern for
women with hormone dependent disease such as breast cancer. There is also concern
about contaminants such as mercury, arsenic lead and pesticides.

I Phytoestrogens

Phytoestrogens are plant substances that have effects similar to those of
estrogens. Preparations vary from enriched
foods such as bread or drinks (soy milk) to more concentrated tablets. The
most important groups are called isoflavones and lignans. The major isoflavones
are genistein and daidzein. The major lignans are enterolactone and enterodiol.

Isoflavones are found in soybeans, chick peas, red clover
and probably other legumes (beans and peas). Oilseeds such as flaxseed are
rich in lignans, and they are also found in cereal bran, whole cereals, vegetables,
legumes and fruit.

The role of phytoestrogens has stimulated considerable interest since populations
consuming a diet high in isoflavones such as the Japanese appear to have lower
rates of menopausal vasomotor symptoms, heart disease, osteoporosis; breast,
colon, endometrial and ovarian cancers. With regard to menopausal symptoms
the evidence from randomized placebo- controlled trials in western populations
is conflicting for both soy and derivatives from red clover. Similarly there
are also debates about the effects on blood fats (lipoproteins), blood vessel
function and blood pressure. The isoflavone daidzein is metabolized extensively
in the gut by the human gut microflora to the more estrogenic secondary metabolite
equol. That only 30% of western populations excrete high levels of equol might
account for the conflicting evidence provided by clinical trials. Genistein
and the synthetic isoflavone ipriflavone may maintain bone mass but the evidence
is conflicting. Additionally, ipriflavone in one study induced lymphocytopenia
in a significant number of women.

II Herbalism

Black cohosh

Black cohosh is widely used to alleviate menopausal symptoms. Early animal
studies suggest an ‘estrogen like' activity; more recent work suggests
the effects may result from a central activity. The results form placebo controlled
trials or comparison with conjugated equine estrogens are promising, but little
is known about long term safety and toxicity.

Kava kava

A Cochrane review concluded that it may be an effective symptomatic
treatment option for anxiety but the data regarding menopausal symptoms are
conflicting. Concern about liver damage has lead regulatory authorities to
suspend or withdraw kava kava.

Evening primrose

Evening primrose oil is rich in gamma linolenic acid. One small placebo-controlled
randomized trial showed it to be ineffective for treating hot flushes, but
it may be helpful for breast tenderness.

Dong quai

Dong quai is commonly used in traditional Chinese medicine.
It has not been found to be superior to placebo in a randomized trial. Interaction
with warfarin and photosensitization have been reported.

Ginkgo biloba

Use is widespread but there is little evidence to show that
it improves menopausal symptoms.

Ginseng

Ginseng has not been found to be superior to placebo in a randomized trial.
Case reports have associated ginseng with postmenopausal bleeding and breast
tenderness; interactions have been observed with warfarin, phenelzine and alcohol.

Others

Wild yam cream , St John's Wort, Agnus Castus (Chasteberry),
Liquorice root and Valerian root are also popular but there is no good evidence
that they have any effect on menopausal symptoms. Claims have been made that
steroids( diosgenein) in yams (dioscorea villosa) can be converted in the body
to progesterone, but this is biochemically impossible in humans.

III Steroids

DHEA (dehydroepiandrosterone)

DHEA is one of the many steroid hormones produced by the adrenal
gland and blood levels drop dramatically with age. DHEA is increasingly being
used in the USA , where it is classed as a food supplement, for its supposed
anti-ageing effects. Some studies have shown benefits on the skeleton, cognition,
well-being, libido and the vagina. There is no evidence that DHEA has any effect
on hot flushes. The short-term effects of taking DHEA are still controversial
and possible harmful effects of long-term use are, as yet, unknown.

Progesterone transdermal creams

Progesterone creams have been advocated for the treatment of menopausal symptoms
and skeletal protection. They have recently been the subject of clinical trials.
Women using the cream have reported improvements in vasomotor symptoms but
there was no effect on bone mineral density. To avoid side effects of progestogens
women who take systemic estrogens may use transdermal progesterone creams for
endometrial protection. No consistent evidence, however, shows that transdermal
progesterone creams can prevent the estrogenic stimulation of the womb lining
(endometrium).

IV Diet and supplements

Vitamins and minerals

Vitamins such as E and C, and minerals such as selenium are
present in various supplements. The evidence that they are of any benefit to
postmenopausal women is extremely limited. While one study showed vitamin E
to reduce hot flushes, the difference between the active and placebo was only
one hot flush per day.

Functional foods

Functional foods generally are defined as foods that confer
a ‘benefit' to the host beyond that of simple nutrition. Four main types
of functional foods may benefit women's health: probiotics, prebiotics, synbiotics
and nutraceuticals. They seem to be most effective in dealing with gastrointestinal
tract disorders but may also be involved in calcium absorption.

V Homeopathy

Homeopathy is generally defined as a system of medical treatment
based on the use of minute quantities of remedies that in larger doses produce
effects similar to those of the disease being treated. The mechanisms underlying
the biological response to ultramolecular dilutions are unclear. Data from
case histories, observational studies and a small number of randmised trials
are encouraging but clearly more research is needed.

VI Other complementary therapies

Other complementary therapies include acupressure, acupuncture,
Alexander technique, Ayurveda, osteopathy, hypnotherapy, reflexology, Reiki
and Tai Chi. A randomized controlled trial of electro-acupuncture has shown
no benefit on menopausal symptoms [Sandberg et al et al 2002]. It is believed
that Tai Chi may benefit older people for fall prevention and conserve bone
mass. Over the last decade, the number of studies on the effect of Tai Chi
has increased rapidly, although it is still limited [Ling et al 2002]. Reflexology
aims to relieve stress or treat health conditions through the application of
pressure to specific points or areas of the feet [Williamson et al 2002]. One
randomized trial has been published so far and no improvement of vasomotor
symptoms was found.

Whilst great care has been taken to ensure the accuracy of information contained
in the fact sheets, the authors and the BMS cannot accept any responsibility
for any errors omissions, mis-statements or mistakes or for any loss or damage
arising from actions or decisions based on information contained in this publication.
Ultimate responsibility for the treatment of patients and interpretation of
published material lies with the medical practitioner. The opinions expressed
are those of the authors, not necessarily those of the BMS. The inclusion in
the publication of material relating to a particular product, method or technique
does not amount to an endorsement of its value or quality, or of claims made
by its manufacturer.